What are the treatment options for prostatitis (inflammation of the prostate gland)?

From the Guidelines

Prostatitis treatment should be guided by the type of prostatitis diagnosed, with acute bacterial prostatitis typically requiring a 2-4 week course of antibiotics, while chronic bacterial prostatitis may need a longer 4-12 week antibiotic course, as suggested by clinical experience, although the optimal durations of treatment are unknown and have not been established by high-quality studies 1. When diagnosing prostatitis, it is essential to differentiate between acute and chronic forms, as well as between bacterial and non-bacterial causes.

• Acute bacterial prostatitis (ABP) often presents with febrile UTI symptoms, and diagnosis relies on clinical presentation and laboratory tests.
• Chronic bacterial prostatitis (CBP) involves more persistent symptoms or recurrent UTIs, and diagnosis may involve comparing bacteria levels in prostatic fluid and urinary cultures. Key considerations in managing prostatitis include:
• The use of antibiotics, such as ciprofloxacin or trimethoprim-sulfamethoxazole, for bacterial prostatitis, with the duration of treatment depending on the severity and type of infection.
• A multimodal approach for chronic prostatitis/chronic pelvic pain syndrome, including alpha-blockers, anti-inflammatory medications, and sometimes muscle relaxants.
• Supportive measures, such as increased fluid intake, warm sitz baths, avoiding alcohol and caffeine, and pelvic floor physical therapy, to help alleviate symptoms. Given the limited quality of evidence and the lack of clear recommendations, a urology consultation may be necessary to determine the best course of treatment for individual patients with prostatitis, as the optimal treatment approach has not been established by high-quality studies 1.

From the FDA Drug Label

1. 8 Chronic Bacterial Prostatitis Levofloxacin tablets are indicated for the treatment of chronic bacterial prostatitis due to Escherichia coli, Enterococcus faecalis, or methicillin-susceptible Staphylococcus epidermidis [see Clinical Studies (14.6)]. Adult patients with a clinical diagnosis of prostatitis and microbiological culture results from urine sample collected after prostatic massage (VB3) or expressed prostatic secretion (EPS) specimens obtained via the Meares-Stamey procedure were enrolled in a multicenter, randomized, double-blind study comparing oral levofloxacin 500 mg, once daily for a total of 28 days to oral ciprofloxacin 500 mg, twice daily for a total of 28 days.

• Levofloxacin is indicated for the treatment of chronic bacterial prostatitis due to Escherichia coli, Enterococcus faecalis, or methicillin-susceptible Staphylococcus epidermidis.
• The recommended treatment duration is 28 days.
• The microbiologic eradication rate by patient infection at 5 to 18 days after completion of therapy was 75% in the levofloxacin group 2.
• Clinical success (cure + improvement with no need for further antibiotic therapy) rates in microbiologically evaluable population 5 to 18 days after completion of therapy were 75% for levofloxacin-treated patients 2.

From the Research

Treatment Options for Prostatitis

• The treatment for acute bacterial prostatitis typically involves oral antibiotics and supportive measures, with hospitalization and broad-spectrum intravenous antibiotics considered for systemically ill patients or those with risk factors for antibiotic resistance 3.
• For chronic bacterial prostatitis, fluoroquinolones are often recommended as first-line agents due to their favorable pharmacological properties, but increasing antibiotic resistance is a significant concern 4.
• Therapy for infectious prostatitis is standardized, with antibiotics as the primary agents, and andrological implications are well-defined with minimal side-effects 5.
• Chronic pelvic pain syndrome (CPPS) therapy aims to reduce pelvic pain, but treatment regimens are not as standardized, and andrological side-effects are well-defined and mainly due to the functional background of these agents 5.

Diagnostic Approaches

• Diagnosis of acute bacterial prostatitis is predominantly made based on history and physical examination, with urinalysis and urine cultures obtained to determine the responsible bacteria and its antibiotic sensitivity pattern 3.
• For chronic bacterial prostatitis, a bacterial localization test is performed to diagnose the condition, and approximately 10% of acute bacterial prostatitis cases eventually develop into chronic bacterial prostatitis 4.
• The Meares-Stamey four-glass test or the two-glass test can be used to differentiate between chronic bacterial prostatitis and chronic pelvic pain syndrome 6.

Antibiotic Therapy

• Typical antibiotic regimens for acute bacterial prostatitis include ceftriaxone and doxycycline, ciprofloxacin, and piperacillin/tazobactam 3.
• Fluoroquinolones, such as levofloxacin, are often used to treat chronic bacterial prostatitis due to their effective prostatic penetration and once-daily dosing 6.
• Antibiotic resistance is a growing concern, and further studies on alternative antibiotics active within the prostate are needed for both prophylaxis and therapy of chronic bacterial prostatitis 4.